An estimated 30% of major depressive disorders are resistant to treatment in the United States. This means a person has tried at least 2 antidepressants for at last 6 weeks each and has not experienced remission or at least a 50% improvement in mood. Two common treatments for this condition are Ketamine or Electroconvulsive therapy for resistant depression. Ketamine has drawn a lot of attention recently. This drug has been studied and administered in controlled, clinical settings to help with treatment-resistant depression and other conditions. Ketamine is an anesthetic and a sedative and has been used to treat suicidal thoughts. . It causes a dissociative experience that makes the brain more malleable and receptive to therapy or alternative ways of thinking. Ketamine influences the neurotransmitter, Glutamate while its causes a cascade of biologic, structural and functional changes in the brain.
Electroconvulsive therapy (ECT) is a medical treatment also used for drug-resistant depression and bipolar disorder. It involves a brief electrical stimulation of the brain to create a generalized cerebral seizure while the person is under anesthesia. Dopamine function is thought to be impaired in people with depression causing impairment in concentration, motivation and pleasure. ECT improves this system while lowering stress hormones and helps feedback regulation.
While both of these treatments have rapid responses (hours to days), is there one better than the other? A meta-analysis was done in which researchers examined 6 studies looking at Ketamine infusions (3 times per week for 2 weeks) and ECT (3 times/week for 4 weeks). Results showed that at 1 month, ECT was significantly more effective than ketamine, with remission rates of 63% versus 43% in the largest study. Both Ketamine and ECT were effective in reducing suicidal ideation. ECT had more cognitive side effects and ketamine was associated with more depersonalization, vertigo and visual disturbance. The effects of both treatments waned over time with comparable outcomes at 3 and 12 months.
There is evidence of long-term maintenance with ECT. Unfortunately, intravenous Ketamine is not reimbursed by insurance companies which is the most bioavailable, precise treatment. Ketamine comes in different forms such as oral, topical, intramuscular, sublingual and intranasal. In the U.S the only FDA-approved form is nasal esketamine (Spravato) but it is only 25-50% bioavailable. Bioavailability means the amount of medication that actually goes to the bodies tissues and the brain. Intravenous treatments are 100% bioavailable. When you take other forms of the drug, parts of the active ingredients don’t go to the bloodstream, but get digested and altered into an unusable form, metabolized and excreted into your body. Although ECT appears to be superior, ketamine might be preferred by those looking for more rapid effects and wanting to avoid ECT’s short-term cognitive effects.
Youth depression rates have risen from 12.9% to 25.2% from pre-pandemic to 2021.
Mental health illness has risen in the United States, with about 20% of people in the country experiencing some form of it. There are many reasons for this sharp increase. The increase can be due to social media, the COVID-19 pandemic, and societal trends resulting in smaller family units, increased financial pressure, social isolation and political and economic stressors. Youth depression rates have risen from 12.9% to 25.2% from pre-pandemic to 2021. More than 50 million Americans struggle with mental illness and most lack access to adequate mental health treatment.
Other brain stimulation treatments include Transcranial magnetic stimulation (TMS) and Vagus nerve stimulation (VNS). Unlike ECT, TMS does not cause a seizure and the patient stays awake through the entire non-invasive process. Rapidly alternating magnetic fields stimulate specific areas of the brain. It is usually administered 4 or 5 times per week for 4-6 weeks. Side effects are usually mild including headaches, twitching and pain at the stimulation site.
Vagus nerve stimulation was originally used to treat seizures but can be effective in treating depression that has not responded to other therapies. It involves implanting an electrical pulse generator under the skin in the patient’s chest that provides intermittent electrical stimulation to the vagus nerve in the neck. Response may take months, so it is not used as a treatment for acute severe depression.
Mental health is so important for our overall health because of its relationship with our physical health. For example, depression raises the risk of diabetes, heart disease and stroke. Similarly, the presence of chronic illnesses can increase the risk of mental illness. Solutions consist of spending time in nature, healthy eating and exercise, connecting with others, reducing stress and getting enough sleep. Other effective treatments include psychotherapy, and many of the above medications or procedures.
Reference: dosomething.org. “11 Facts About Mental Health”. 2023.
Zimmerman, R. Ketamine for depression: What it feels like and who it can help. The Washington Post. 9/12/2022.
The American Psychiatric Association. What is Electroconvulsive therapy? Psychiatry.org
Principium Psychiatry. IV vs Oral Intramuscular vs Intranasal Ketamine: Why route matters. principiumpsychiatry.com
Rhee TG et al. Efficacy and safety of ketamine vs electroconvulsive therapy among patients with major depressive episode: A systemic review and meta-analysis. JAMA Psychiatry 2022. Oct 19; [e-pub]. (https://doi.org/10.1001/jamapsychiatr. 2022.3352)
Brain Therapy TMS: Transcranial magnetic Stimulation. Top 5 treatment-resistant depression statistics you need to know. May 28, 2021.